Why won’t these hives go away? What your recurring rash might really be telling you

It starts without warning. A sudden, intense itch. Then the hives appear – angry, burning, red – creeping across her arms and legs, disrupting her work, her sleep, her plans.

For a 35-year-old female patient, referred to in this article as Patient R, this unwanted companion has been showing up since November 2020. And for a long time, she had no idea why.

Initially, she tried her best to endure them, slathering them with moisturising cream. Spoiler alert: They did not work, and her symptoms continued to recur for more than six weeks, often without a clear trigger.

These persistent recurrences prompted her to consult a general practitioner (GP), to no avail.

Her condition was diagnosed by the GP as hives, and they did not go into much detail. She was sent home with moisturising cream and steroid cream and her condition did not improve.

Subsequent visits to two other GPs yielded the same results. Patient R was frustrated – not only by the incessant itching, but also at the lack of a solution and multiple clinic visits.

In addition, her condition continued to affect her life, including her sleep, work productivity, travel and social activities.

Her confidence also took a hit, as she turned to wearing long-sleeved clothes to cover up, even in Singapore’s humidity, and had to turn down important work assignments due to the incessant itch.

Eventually, in October 2021, she found relief.

The third GP Patient R visited diagnosed her condition as chronic spontaneous urticaria, also known as CSU or chronic hives. It is not contagious.

She was given antihistamines, with the treatment gradually adjusted over the course of her next appointments. Today, her condition is under control, but she continues to carry her medicines with her especially when travelling – just in case.

What is CSU?

Patient R is among the 1 per cent of people worldwide living with CSU – and she is far from alone in how long it took to get answers.

The condition is more common than many realise, particularly among women. According to Dr Lynn Chiam, consultant dermatologist at Mount Elizabeth Novena Hospital’s Children & Adult Skin Hair Laser Clinic, CSU affects women twice as often as men, and most commonly strikes young to middle-aged adults.

So what exactly is it? At its core, CSU is a long-term skin condition where hives, deep skin swelling, or both, keep returning for more than six weeks – with no identifiable cause. It is neither an allergy, nor a heat rash, even though it can look remarkably similar.

“It usually appears as raised, itchy hives that can be red or skin-coloured,” says Dr Chiam. “Some people also experience swelling of the lips, eyelids, hands or feet. The itch can be intense – sometimes burning or painful – and severe enough to disrupt sleep.”

What makes CSU particularly confusing is that nothing obvious seems to set it off. Unlike a food allergy or a reaction to an insect bite, there is no clear trigger to avoid. Instead, the condition stems from the immune system misfiring – activating when it should not, and causing flare-ups that seem to come out of nowhere.

The hives may disappear after a few hours, only to return days later. This stop-start pattern often leads people to dismiss it as stress, a passing reaction, or just bad skin. 

But Dr Chiam cautions against waiting it out: “When it keeps recurring for weeks or months, it is a chronic condition that deserves proper medical attention.” Left unaddressed, CSU can persist for many months – or even years.

Patient advocacy is key

This frustration and multiple GP visits were shared by a male patient, referred to in this article as Patient D, who first spotted welts on his limbs and torso in June 2020.

Similarly, the 37-year-old first turned to over-the-counter antihistamines and even sought advice from his family. 

Only after six months and three visits to his GP did Patient D receive a referral to visit a dermatologist. Meanwhile, he struggled with disrupted sleep and had to reduce his participation in sports and social activities.

His fitness and social life also suffered, with him losing muscle mass as a result of the lack of exercise, and he drifted from his friends.

Even when Patient D was promptly diagnosed with CSU by the dermatologist in June 2021, he felt he still did not understand much about this condition.

Dr Chiam weighs in: “CSU’s unpredictable nature, swelling and the often-long journey to get a proper diagnosis usually lead to greater, more abrupt quality of life reduction than other skin conditions like atopic eczema. Most patients assume that CSU is due to allergies and will take great pains to avoid the triggers like foods and materials that they think cause the hives.”

She adds that the time to confirm diagnosis also ranges widely from weeks to one to two years, depending on the patient. “Referral to a dermatologist may take additional time, extending the period of suffering with uncertainty and ongoing symptoms like sleep deprivation.”

Presently, Patient D receives treatment focused on controlling symptoms and continues to follow up with the dermatologist annually. 

Treatments available and what to tell your doctor

The first-line treatment for CSU is non-sedating antihistamines taken regularly and not as and when there are flare-ups, says Dr Chiam. 

However, many patients remain symptomatic despite antihistamines. “In global studies, approximately half of patients continue to experience symptoms even with treatment.

“For this group, alternative therapies are available. There are targeted treatments that are designed to act on specific parts of the immune pathway involved in CSU,” she adds.

Patients should see a GP if hives or swelling keep recurring for more than six weeks without a clear trigger. If symptoms persist, ask whether referral to a dermatologist is appropriate. 

Be sure to also get the cameras ready. Dr Chiam advises patients to prepare the following for their appointment: photos of flare-ups, a symptom timeline and notes on how their condition affects their daily routine.

“It is also helpful to describe the pattern clearly, for example, ‘This itchy rash appears at least four times a week.’ Naming the duration is key to raising suspicion of CSU. This helps doctors see the full picture and is the key trigger for diagnosis and treatment escalation.”

Ultimately, the goal is to achieve greater public awareness, so people feel socially permitted to take symptoms seriously and speak up.

“By naming the condition and validating patient experiences, we can move from dismissal to understanding, and from repeated short-term fixes to more appropriate long-term management,” she says.

Patients ‘R’ and ‘D’ are composite profiles reflecting the lived experiences of people with CSU.

Find out more about chronic spontaneous urticaria (CSU) and how to manage it.